Sticky Dollars: Inertia in the Evolution of Federal Allocations for HIV Care through the Ryan White HIV/AIDS Program

Abstract Background: Community Health Workers (CHWs) have long been integrated in the delivery of HIV care, in middle- and low-income countries. However, less is known about CHW integration into HIV care teams in the United States (US). To date, US based CHW integration studies have studies explored integration in the context of primary care and patient-centered medical homes.There is a need for research related to strategies that promote the successful integration of CHWs into HIV care delivery systems. In 2016, the Health Resources and Services Administration HIV/AIDS Bureau launched a three-year initiative to provide training, technical assistance and evaluation for Ryan White HIV/AIDS Program (RWHAP) recipient sites to integrate CHWs into their multidisciplinary care teams, and in turn strengthen their capacity to reach communities of color and reduce HIV inequities. Methods: Ten RWHAP sites were selected from across eight states. The multi-site program evaluation included a process evaluation guided by RE-AIM to understand how the organizations integrated CHWs into their care teams. Site team members participated in group interviews to walk-the-process during early implementation and following the program period. Directed content analysis was employed to examine program implementation. Codes developed using implementation strategies outlined in the Expert Recommendations for Implementing Change project were applied to group interviews (n=20). Findings: Implementation strategies most frequently described by sites were associated with organizational-level adaptations in order to integrate the CHW into the HIV care team. These included revising, defining, and differentiating professional roles and changing organizational policies. Strategies used for implementation, such as network weaving, supervision, and promoting adaptability, were second most commonly cited strategies, followed by training and TA strategies. Conclusions: Wrapped up in the implementation experience of the sites there were some underlying issues that pose challenges for health care organizations. Organizational policies and the ability to adapt proved significant in facilitating CHW implementation. The integration of the CHW role may present an occasion for health care delivery organizations to reassess policies that may unintentionally marginalize communities and both limit career opportunities and patient engagement.

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Medicaid Expansion’s Impact on HIV Outcomes in a Non-urban Southeastern Ryan White HIV/AIDS Program Clinic

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa595 ◽

2020 ◽

Author(s):

Kathleen A McManus ◽

Karishma Srikanth ◽

Samuel D Powers ◽

Rebecca Dillingham ◽

Elizabeth T Rogawski McQuade

Keyword(s):

Private Insurance ◽

Hiv Care ◽

People Living With Hiv ◽

Insurance Status ◽

Engagement In Care ◽

Poverty Level ◽

Medicaid Enrollment ◽

Ryan White ◽

Aids Program ◽

Hiv Aids

Abstract Background While the Ryan White HIV/AIDS Program (RWHAP) supports high-quality HIV care, Medicaid enrollment provides access to non-HIV care. People living with HIV (PLWH) with Medicaid historically have low viral suppression (VS) rates. In a state with previously high Qualified Health Plan coverage of PLWH, we examined HIV outcomes by insurance status during the first year of Medicaid expansion (ME). Methods Participants were PLWH ages 18-63 who attended ≥1 HIV medical visit/year in 2018 and 2019. We estimated associations of sociodemographic characteristics with ME enrollment prevalence and associations between insurance status and engagement in care and VS. Results Among 577 patients, 151 (33%) were newly eligible for Medicaid, and 77 (51%) enrolled. Medicaid enrollment was higher for those with incomes <100% Federal Poverty Level (adjusted prevalence ratio [aPR] 1.67; 95% confidence interval [CI] 1.00-1.86) compared to others. Controlling for age, income, and 2018 engagement, those with employment-based private insurance (adjusted risk difference [aRD] -8.5%, 95% CI -16.9-0.1) and Medicare (aRD -12.5%, 95% CI -21.2- -3.0) had lower 2019 engagement than others. For those with VS data (n=548), after controlling for age and baseline VS, those with Medicaid (aRD -4.0%, 95% CI -10.3-0.3) and with Medicaid due to ME (aRD -6.2%, 95% CI -14.1- -0.8) were less likely to achieve VS compared with others. Conclusions Given that PLWH who newly enrolled in Medicaid had high engagement in care, the finding of lower VS is notable. The discordance may be due to medication access gaps associated with changes in medication procurement logistics.

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“Part of getting to where we are is because we have been open to change” integrating community health workers on care teams at ten Ryan White HIV/AIDS program recipient sites

BMC Public Health ◽

10.1186/s12889-021-10943-1 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Linda Sprague Martinez ◽

Melissa Davoust ◽

Serena Rajabiun ◽

Allyson Baughman ◽

Sara S. Bachman ◽

...

Keyword(s):

Program Implementation ◽

Technical Assistance ◽

Health Workers ◽

Implementation Strategies ◽

Hiv Care ◽

Organizational Policies ◽

Ryan White ◽

Aids Program ◽

Group Interviews ◽

Hiv Aids

Abstract Background Community Health Workers (CHWs) have long been integrated in the delivery of HIV care in middle- and low-income countries. However, less is known about CHW integration into HIV care teams in the United States (US). To date, US-based CHW integration studies have studies explored integration in the context of primary care and patient-centered medical homes. There is a need for research related to strategies that promote the successful integration of CHWs into HIV care delivery systems. In 2016, the Health Resources and Services Administration HIV/AIDS Bureau launched a three-year initiative to provide training, technical assistance and evaluation for Ryan White HIV/AIDS Program (RWHAP) recipient sites to integrate CHWs into their multidisciplinary care teams, and in turn strengthen their capacity to reach communities of color and reduce HIV inequities. Methods Ten RWHAP sites were selected from across eight states. The multi-site program evaluation included a process evaluation guided by RE-AIM to understand how the organizations integrated CHWs into their care teams. Site team members participated in group interviews to walk-the-process during early implementation and following the program period. Directed content analysis was employed to examine program implementation. Codes developed using implementation strategies outlined in the Expert Recommendations for Implementing Change project were applied to group interviews (n = 20). Findings Implementation strategies most frequently described by sites were associated with organizational-level adaptations in order to integrate the CHW into the HIV care team. These included revising, defining, and differentiating professional roles and changing organizational policies. Strategies used for implementation, such as network weaving, supervision, and promoting adaptability, were second most commonly cited strategies, followed by training and Technical Assistance strategies. Conclusions Wrapped up in the implementation experience of the sites there were some underlying issues that pose challenges for healthcare organizations. Organizational policies and the ability to adapt proved significant in facilitating CHW program implementation. The integration of the CHWs in the delivery of HIV care requires clearly distinguishing their role from the roles of other members of the healthcare delivery team.

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1030. Medicaid Expansion: How Does it Impact HIV Outcomes in One Non-urban Southeastern Ryan White HIV/AIDS Program Clinic?

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1216 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S544-S546

Author(s):

Kathleen A McManus ◽

Karishma R Srikanth ◽

Samuel D Powers ◽

Rebecca Dillingham ◽

Elizabeth T Rogawski McQuade

Keyword(s):

Viral Suppression ◽

Hiv Care ◽

Baseline Viral Load ◽

Medicaid Expansion ◽

Engagement In Care ◽

Medicaid Enrollment ◽

Ryan White ◽

Aids Program ◽

Research Grant ◽

Hiv Aids

Abstract Background People living with HIV (PLWH) with Medicaid historically have lower viral suppression (VS) rates than those with other insurance. VS rates with Medicaid expansion (ME) are unknown. We examined HIV outcomes (engagement in care, VS) by insurance status for a non-urban Southeastern Ryan White HIV/AIDS Program (RWHAP) Clinic cohort for year after ME. Methods Participants were PLWH ages 18-63 who attended > 1 HIV medical visit/year in 2018 and 2019. Log-binomial models were used to estimate the association of characteristics with Medicaid enrollment prevalence and one-year risks of engagement in care and VS in 2019. Results Among 577 patients, 241 (42%) were newly eligible for Medicaid due to ME and 79 (33%) enrolled (Figure 1a). For those without Medicare, Medicaid enrollment was higher for those with incomes < 100% FPL (adjusted prevalence ratio [aPR] 1.67; 95% confidence interval [CI] 1.00-1.86) compared to those with incomes > 101% FPL. Those enrolled in Medicaid due to ME had 87% engagement in care compared to 80-92% for other insurance plans (Figure 1b). Controlling for 2018 engagement, older age (adjusted risk ratio [aRR] for 10 years 1.03, 95% CI 1.00-1.05; Table 1) was associated with being engaged in 2019. Engagement was lower for those with employment-based insurance (aRR 0.91, 95% CI 0.83-0.99) and Medicare (aRR 0.87, 95% CI 0.78-0.96). Of those with viral loads in 2018 and 2019 (n=549), those who newly enrolled in Medicaid due to ME had 85% VS compared to 87-99% for other insurance plans (Figure 1c). In univariate analysis, age, income, and baseline viral load status were associated with viral suppression (Table 2), and those with Medicaid due to ME (aRR 0.90, 95% CI 0.81-1.00) were less likely to achieve VS compared with others. Figure 1 Table 1 Table 2 Conclusion The low uptake of ME was likely influenced by many PLWH already having Medicare. While the RWHAP supports high quality HIV care, Medicaid enrollment improves access to non-HIV care and should be supported by RWHAP. Given that engagement in care was high for PLWH who newly enrolled in Medicaid, the finding of lower VS is surprising. The discordance may be due to medication access gaps associated with changes in pharmacy logistics. Future studies with larger cohorts will need to examine how ME contributes to PLWH’s overall health and to ending the HIV epidemic. Disclosures Kathleen A. McManus, MD, MSCR, Gilead Sciences, Inc (Research Grant or Support, Shareholder) Rebecca Dillingham, MD, MPH, Gilead Sciences, Inc (Research Grant or Support)Warm Health Technologies, Inc (Consultant)

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HIV and Aging: Multimorbidity in Older People Living with HIV in One Non-Urban Southeastern Ryan White HIV/AIDS Program Clinic

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa584 ◽

2020 ◽

Author(s):

Elizabeth C Arant ◽

Ceshae Harding ◽

Maria Geba ◽

Paul V Targonski ◽

Kathleen A McManus

Keyword(s):

Private Insurance ◽

Female Gender ◽

Hiv Care ◽

People Living With Hiv ◽

Medical Visit ◽

Age Related ◽

Ryan White ◽

Aids Program ◽

Living With Hiv ◽

Hiv Aids

Abstract Background Age-related chronic conditions are becoming more concerning for people living with HIV (PLWH). We aimed to identify characteristics associated with multimorbidity and evaluate for association between multimorbidity and HIV outcomes. Methods Cohorts included PLWH aged 45-89 with >1 medical visit at one Ryan White HIV/AIDS Program (RWHAP) Southeastern HIV clinic in 2006 (Cohort 1) or 2016 (Cohort 2). Multimorbidity was defined as >2 chronic diseases. We used multivariable logistic regression to assess for associations between characteristics and multimorbidity and between multimorbidity and HIV outcomes. Results Multimorbidity increased from Cohort 1 (n=149) to Cohort 2 (n=323) (18.8% vs 29.7%, p<0.001). Private insurance was associated with less multimorbidity than Medicare (Cohort 1: adjusted Odds Ratio [aOR] 0.15, 95% Confidence Interval [CI] 0.02-0.63; Cohort 2: aOR 0.53, 95% CI 0.27-1.00). In Cohort 2, multimorbidity was associated with female gender (aOR 2.57, 95% CI 1.22-5.58). In Cohort 1, Black participants were less likely to be engaged in care compared to non-Black participants (aOR 0.72, 95% CI 0.61-0.87) Cohort 2, participants with rural residences were more likely to be engaged in care compared to those with urban residences (aOR 1.23, 95% CI 1.10-1.38). Multimorbidity was not associated with differences in HIV outcomes. Conclusions While PLWH have access to RWHAP HIV care, PLWH with private insurance had lower rates of multimorbidity, which may reflect better access to preventative non-HIV care. In 2016, multimorbidity was higher for women. The RWHAP and RWHAP Part D could invest in addressing these disparities related to insurance and gender.

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